My Life Counsel's Financial Assistance Program Application

My Life Counsel Financial Assistance Program

We understand that seeking therapy is a significant investment. My Life Counsel offers a limited Financial Assistance Program to help families in need access vital care.

This program is funded entirely through the My Life Counsel Benevolence Fund, supported by community donations and grants. Because this funding source is limited, we carefully manage it to assist as many families as we can.

The Application Process

To apply for assistance, please follow the steps below:

Submit Your Request: Complete and submit the financial assistance form located below.
Board Review: Your submission will be reviewed and must be approved by our Board of Directors.
Receive Offer: If approved, you will receive an email from us offering a discounted, sliding scale rate.
Confirm and Schedule: Once you accept the offer, you will receive a confirmation email, and we will move forward with scheduling your first appointment with a therapist.

Important Note on Timing: Please note that the review and approval process can take one day or up to ten days. We greatly appreciate your patience and understanding as we carefully consider every submission.

Financial Assistance Program Application

1. First and last name of person(s) responsible

2. Phone

3. Email

4. List name, relationship, and ages of household occupance

6. Source of income and/or place of employment

7. Do you have insurance?

8. Please any other financial support or incoume .

9. Please write a brief explanation of your financial hardship.

10. Who is your current therapist or who provided you with this application?

11. By checking the boxes below, I understand and agree to the Financial Assistance Program’s guidelines and policies. Required

1. To my knowledge, all of the statements and choices on this form are accurate and true.

2. All session reschedules and/or cancellations that are less then 36 hours will be considered a charged session.

3. More than three reschedule and/or cancellations will result in a discharge, and a “payback” process will ensue.

4. A debit or credit card must be on file for guideline noncompliance.

Thanks for submitting!